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Article:

Bassah, N., Cox, K. and Seymour, J. orcid.org/0000-0002-9384-2551 (2018) Preregistration nursing students' experiences of a palliative care course in a resource-poorsetting. International Journal of Palliative Nursing, 24 (8). pp. 388-397. ISSN 1357-6321

10.12968/ijpn.2018.24.8.388

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Published in: International Journal of Palliative Nursing, 2018 Aug

2;24(8):388-397. doi: 10.12968/ijpn.2018.24.8.388.

Preregistration nursing students’ experiences of a palliative care

course in a resource-poor setting

Nahyeni Bassah1, Karen Cox 2 and Jane Seymour 3

1. Assistant Lecturer of Nursing, Department of Nursing, Faculty of Health Sciences, University of Buea, South-West Region, Cameroon

2. Vice-Chancellor and President, University of Kent, Canterbury, Kent, UK

3. Professor of Palliative and End-of-life Care, School of Nursing and

Midwifery, University of Sheffield, UK

2

Abstract:

Background: Palliative care education for non-specialist healthcare

professionals is an important strategy for widening access to palliative care.

Aim: To describe Cameroonian nursing students’ experiences and

perceptions of the strengths and weaknesses of a palliative care course,

with a view to refining the course.

Methods: Three focus groups were conducted with 23 students and data

analysed thematically using the framework approach.

Findings: The students reported connecting with their past personal and

professional experiences in the care of patients with palliative care needs,

during the course. The main course strength reported was its use of a

variety of interactive educational strategies like role plays, group

discussions and case studies and its main weakness was the lack of

supervised clinical practice in palliative care.

Conclusion: The use of a variety of interactive educational strategies,

including supervised clinical practice is considered by nursing students as

vital to enhancing learning in palliative care education. However, the lack

of supervised palliative care clinical practice opportunities is a challenge for

Cameroon.

Keywords:

Palliative care curriculum; pre-registration nursing education; resource-

poor countries; curriculum development.

3

Key Points

Preregistration nursing students in a resource-poor country report a

felt need for palliative care education.

They value educational approaches that are interactive and which

include a variety of strategies.

They consider supervised clinical practice placement in a palliative

care setting important for effective learning about palliative care.

Background

The Worldwide Palliative Care Alliance (WPCA 2014) estimates that the

large majority (78%) of the adult population in need of palliative care reside

in resource-poor countries. This includes people suffering from chronic and

life-threatening illnesses like: cancer, HIV/AIDS cardiovascular and

respiratory diseases, and problems related to ageing. In Cameroon, about

4.5% of the adult population (aged 19-49 years) are estimated to be living

with HIV (USAID, 2015), and there is an upsurge of non-communicable

chronic diseases, accounting for approximately 31% of all deaths annually

(WHO, 2014; Echouffo-Tcheugui and Kengne, 2011). For most patients, the

substantial suffering associated with living and dying from these conditions

is amendable to palliative care interventions, if available (Payne et al.,

2008).

The education of healthcare providers in palliative care is recognized as an

important strategy for the improvement of the care of patients with life-

threatening and chronic conditions and their families (Worldwide Palliative

4

Care Alliance, 2014) (Box 1). This demands that relevant curricula are

developed (Stjernsward et al., 2007). Initiatives in palliative care education

for preregistration nursing students are developing rapidly internationally,

although they are more common in resource-rich countries (Cavaye and

Watts 2014; Bassah et al., 2014; Cavaye and Watts, 2012; Dickenson et

al., 2008). Several innovative and contextually feasible approaches to

palliative care education have been employed (Box 2). However, there is

limited evidence about the effectiveness of the various educational

approaches that have been used so far. An important component in the

development of any educational program is its evaluation, as this is vital to

determining the value/worth the program, as well as to informing its

enhancement (Frey et al., 2012).

Box 1: Some principles of palliative care nursing

Palliative care nursing:

values a caring attitude, that involves sensitivity, empathy and

compassion, and demonstrates concern for the individual;

considers the patient as a unique individual;

recognises and respects cultural differences and ensures

planned care is culturally acceptable;

ensures the consent of a patient, or those to whom the

responsibility is delegated, is sought before any care is given

or withdrawn;

values good communication with patients and between the

wider healthcare team involved in a patient’s care;

ensures appropriate care is offered to the stage of the patients’ illness, with all efforts directed at the relief of suffering and the

quality of life, and not necessarily at the prolongation of life;

offers the best possible care that is available and appropriate;

pays particular attention to the needs of family care givers of

patients with life-threatening and chronic conditions;

Adapted from: International Association for Hospice and Palliative Care:

http://hospicecare.com/about-iahpc/publications/manuals-guidelines-

books/getting-started/6-principles-of-palliative-care

5

Box 2: Some approaches that have been employed in preregistration palliative care education

A review by the authors revealed that, while studies exist that have

evaluated preregistration palliative care educational programs, these are

predominantly focused on the impact on nursing students’ palliative care

competencies and have employed quantitative methods of data collection

and analysis (Bassah et al., 2014). There are relatively few studies that

Using a theoretical package alongside placement

learning at a hospice, a funeral home, and an anatomy

laboratory (Mallory, 2003).

Combining interactive classes with experts, reading of

recommended texts, field trips and online discussions

(Thompson 2005).

Using lectures, supplemental texts, hospice and funeral

home visits and cinemeducation approach by using a

film called the ‘Wit,’ (Dobbins, 2011) Using a workshop approach incorporating emotionally

charged learning activities through lectures, clinical

case studies, individual and plenary reflective activities,

viewing of a documentary film and role-playing

simulations (Brien et al., 2008)

Using student volunteers as companions of dying

patients and their families (Kwekkeboom et al., 2006).

Having students to keep a diary about their palliative

care experiences and sharing stories about personal

loss (Weismann, 2011).

Employing clinical simulations using high fidelity patient

scenarios (Eaton et al., 2012; Fluharty et al., 2012;

Moreland et al., 2012; Leighton and Dubas, 2009)

6

have explored nursing students’ feelings about, or their reactions to,

palliative care education (Moreland et al., 2012; Dibartolo and

Seldomridge, 2009; Brien et al., 2008). Yet it is well established that

evaluative feedback from learners is vital to the curriculum evaluation

process (Ranasinghe et al, 2011; Kern et al., 1998), particularly given the

shift towards learner-centered approaches in education (Coe et al., 2012).

This paper reports data from focus groups conducted as part of a wider

study to evaluate a 30 hour course in palliative care for pre-registration

nursing students (Bassah, 2016). The study employed a quasi-

experimental single group pretest/posttest design with an associated

qualitative strand (critical incident interviews and focus groups). The focus

groups were used to understand students’ experiences of the course, their

perceptions of its strengths and weaknesses and views about how it could

be improved. The wider evaluation sought to understand the impact of the

course on students’ knowledge and self-perceived competence and

confidence in palliative care, and the transfer of their palliative care learning

to practice (Figure 1). The course evaluation strategy was informed by the

Kirkpatrick’s evaluation model (Hedges and Wee, 2014).

7

Figure 1: Diagrammatic presentation of the main study design

Phase I:

Pre-Intervention

Course development Via:

Review of preregistration

palliative care education,

Review of core and sample

curricula,

Consultation with expert

palliative care

practitioners, educators

and researchers.

Phase II:

Intervention Phase

The Palliative care

course

Delivery of a 30 hour

classroom-based course by

nurse educators, palliative

care nurses and a chaplain

in Cameroon to 2nd and 3rd

year preregistration student

nurses of the pilot

University.

Phase III: Post-Intervention-Evaluation Phase

ふヲ Mﾗﾐデｴゲ ;aデWヴ ｷﾐデWヴ┗Wﾐデｷﾗﾐが ;デ デｴW WﾐS ﾗa ゲデ┌SWﾐデゲげ ヴWｪ┌ﾉ;ヴ ヮﾉ;IWﾏWﾐデ experience)

Posttest of

students’:

Palliative care

knowledge

Self-perceived

competence and

confidence in

palliative care

provision

Focus Groups exploring

students’ perception of:

The impact of the course

on their palliative care

knowledge and

competence and

confidence in palliative

care provision

Their experiences of the

course

The strength and

weaknesses of the course

and how it can be

enhanced

Their transfer of learning

to clinical practice during

internship and the

facilitators and barriers

to this transfer

Individual

critical incident

interviews to

explore students’

Transfer of their

learning to

practice and the

facilitators and

barriers to this

transfer

Pretest of students’:

Palliative care knowledge

Self-perceived

competence and

confidence in palliative

care provision.

(First day of the course)

Indicates the component

of the study reported in

this paper

8

Findings relating to students’ transfer of their learning to practice, showing

that students could transfer their palliative care knowledge to practice,

although there existed some barriers, have been previously published

(Bassah et al., 2016). The findings on the impact of the course on students’

palliative care knowledge and self-perceived competence and confidence in

palliative care will be reported elsewhere (Bassah, 2016).

Study Context

This study was conducted in one University in Cameroon which offers a

Bachelors of Nursing Science degree program. Palliative care education in

Cameroon is currently limited, particularly at the preregistration level,

although some palliative care education seminars have been implemented

with qualified nurses (Bassah et al., 2016). We therefore developed a

classroom based palliative care course for preregistration nursing students,

comprising 30 hours of content, including: the philosophy of palliative care,

communication and breaking bad news, pain and symptom management,

ethical, legal and cultural issues in palliative care, care at the time of death

and after death care, and bereavement management. This course was fitted

into the nursing curriculum of the pilot university and offered as an option

to student nurses. It was delivered to second and third year nursing

students by nurse educators, palliative care clinical nurses and a chaplain

in Cameroon. The course was underpinned by the experiential learning

theory (Kolb, 1984) and was delivered using both didactic and experiential

9

educational strategies like lecture assisted with PowerPoint, videos, case

studies, interactive demonstrations, small group discussions and role plays.

Palliative care educational resources including palliative care manuals,

toolkits, textbooks and DVD players were available to students and

facilitators during the course. On each of the 5 days of the course, three 2

hour sessions were presented by either two or three facilitators. The

philosophy of palliative care as well as communication and breaking bad

news were delivered on the first and second day of the course. Pain

assessment and management was covered on the third day, symptom

management and psychosocial and ethical issues were presented on the

fourth day and care at the time of death, spiritual care and bereavement

management were covered on the fifth day. Upon completion of the course,

students undertook their regular clinical placement in some wards like the

medical, surgical, outpatient paediatric, and haemodialysis wards of a local

hospital, under the supervision of their regular placement mentors. It was

hoped that during this clinical placement students will encounter patients

with life-threatening/chronic conditions and or dying patients, with the

opportunity to implement their learning from this course, as well enhance

their palliative care skills. More details about the course development and

implementation can be obtained from Bassah et al. (2016).

Methods

Study Design

10

The focus group method was used to collect data for this component of the

study (Figure I: Red Highlights). Given that the students studied together

during the palliative care course, the focus group method was considered

a realistic and natural way to access diverse course experiences and

evaluations. We also felt we could capture deep and rich information in a

more economic manner than by using individual interviews (Kress and

Shoffner 2007).

Participants

The study participants were second and third year nursing students. Sixty

nine students registered for the palliative care course and 64 completed all

sessions of the course. A stratified purposeful simple random sampling

technique was used to select participants for the focus groups in order to

allow sufficient exploration and detection of consensus within and across

groups, and ultimately increase rigour (Addington-Hall, 2007; Kitzinger,

2005). The course registration forms were used to facilitate this process.

Every student on the registration form was a potential participant for the

focus group interview if they gave consent to do so. A ballot of students in

the various strata (female second year students, male second year

students, female third year students, male third year students) was made

and the selected student invited to participate by phone call. Eight students

were invited per focus group (four students each from the second and third

year class).

Ethical Considerations

11

Ethical approval for this study was obtained from the ethics review boards

of the Faculty of Medicine and Health sciences, University of Nottingham

and the Institutional Review Board of the Faculty of Health Sciences of the

University of Buea, Cameroon. Study participants received the study

information sheet and signed an informed consent form prior to

participation. Participants’ individual identity was kept confidential

throughout the research process and anonymity and confidentiality were

also ensured.

Data collection and analysis

The focus groups were conducted two months after course completion,

when students had completed their regular semester clinical placement and

in order to enhance reflections on experiential learning, which was the

underpinning theoretical framework of the course. The focus groups were

conducted in classrooms on campus, using an aide memoire and were audio

taped. The development of this aide memoire was informed by findings

from our review of literature about the education of preregistration nursing

students in palliative care (Bassah et al. 2014), and taking into

consideration the aim of the course evaluation process. Sessions were

moderated by the lead author, with a research assistant as note taker.

Data were transcribed verbatim and analysed thematically, using the

framework approach (Gale et al., 2013; Braun and Clarke, 2006), by the

lead author under the academic supervision of JS and CK.

12

The analysis was started by close examination of data from one focus

group. Initial coding of the data was undertaken with the research

questions and the Kirkpatrick’s model for training program evaluation in

mind. However, we also remained opened to emerging issues from the

narratives of research participants. This initial analysis was used to develop

an analytical framework which was applied to the data from the other two

focus groups, while checking for any new codes. This allowed for the

formation of subcategories which were then gradually grouped together

into main categories (table 1).

Table 1: Categories and Subcategories

Results

Category Subcategory 1 Subcategory 2

Students’ report of their experiences during the

course

Connecting with and reflecting on

past experiences of end of life care

Realization of the importance of

palliative care

Ambiguity of feelings about the

course.

Students’ evaluations of the course and how it

can be enhanced

Students’ perceptions of the Strengths of the course

The use of a variety of

educational strategies

The novelty and relevance of

course content

Students’ perception of the Weaknesses of the course and

suggestions for enhancement

Lack of a supervised clinical

practice in palliative care

nursing curricula

Work overload and extensive

course duration

Poor facilitation

Poor psychological climate

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Three focus groups were conducted with 23 students, as one of the invited

students did not attend the focus group. The results obtained are presented

under two main themes: students’ experiences of the course and their

evaluation of its strengths and weaknesses.

I. Students’ report of their experiences during the course

Students expressed varying experiences during the course, both positive

and negative. However, generally, the course was well received by the

students. Their experiences included:

A. Connecting with and reflecting on past experiences of end of

life care

The palliative care course seems to have made students to connect with,

reflect on and synthesize their past personal and professional experiences

in the care of patients with palliative care needs. During the course,

students were engaged with re-examining and re-evaluating their past

experiences in palliative care and thinking about how better they could

practice in the future. These connections and reflections seemed to enable

self-assessment and learning for the students.

“When I reflected back at home on what happened when my step

mother died. She died in pain, of cancer pain... and I regretted, if I

had done this course before, I would have helped her to die

peacefully” (FG2P3).

[FG1P2 = Focus Group # 1 participant #2]

14

B. Realization of the importance of palliative care

Participating in the palliative care course seems to have enhanced students’

understanding of the need for palliative care, and how important palliative

care education is to nursing. It made them to reflect on the need to include

palliative care in their nurse training curriculum.

“It is, from the course I discovered that it (palliative care) is an

integral part of nursing and should be included in the training

program” (FG3P6).

“Before, I did not know the meaning of palliative care. This course

has been a real eye opener…I only knew that if you have HIV/AIDS,

you are just like someone who has malaria…I did not have any idea

that you needed to take care of these people, so that they can have

a good quality of life…the course has really helped me a lot”. (FG3P4).

C. Ambiguity of feelings about the course

In one of the focus groups, students had a discussion about whether or not

they liked the course. Some students, while being of the opinion that the

course was beneficial in improving their palliative care competencies, said

they did not like the course because it concerned dying. However, others

thought the course was worthwhile, even though it focused on dying. This

ambivalence of view is demonstrated in the following interaction.

FG2P3: “For me…I don’t actually like it (the course), because, I

cannot be dealing with clients that are terminally ill... working with

15

people that are in great difficulties... who are asking you some types

of questions, why is it me?, when will I die”?

FG2P6: “To me, I like the course, because… it gives me so much joy

to see a patient who knows that what I have cannot be cured... but

at least my quality of life will be improved and they are happy about

it”.

II. Students’ evaluations of the course and how it can be enhanced

A. Students’ perceptions of the Strengths of the course

i. The use of a variety of educational strategies

Most students greatly appreciated the use of a variety of student centered

teaching methods during the course. They reported that the educational

strategies used promoted interactions among students and facilitators.

They found these to be more stimulating and interesting and reported it

was significant to increasing their motivation, participation and enthusiasm

for the course, thus enhancing their learning.

“One of the methods that were used during the sessions that really

enhanced my learning was the teaching styles. It was more students

centered... more interactive” (FG1P2).

They particularly talked about the use of role plays, case studies, group

discussions and sharing of personal experiences as well as the use of

pictures. These they said were effective in making the course practical and

giving them an opportunity to rehearse skills in a safe and supportive

environment. The experience of photographs which showed how patients

16

with life-threatening conditions might present was seen as providing

anticipatory guidance for what they might experience in clinical practice.

“In line with what she said, when [name of facilitator withheld] came

for his own session, I really enjoyed it. The manner in which he

tackled the various modes the patient could portray, it was really

interesting… putting it practically... he gave me some insights…that I

could apply when I am in the clinical setting” (FG3P8).

“I am really in line with what [FG3P5] has said because seeing the

type of conditions that they showed to us, they were conditions that

were really critical and I have never seen such before... I knew that

after this course I should be prepared to face those types of

challenges, so, that really made me to be more prepared for palliative

care” (FG3P6).

A few students said assessing their prior knowledge at the beginning of the

course was vital. They reported that the pretest, which was one of the

methods used to assess the impact of the course on students’ palliative

care knowledge, (Bassah, 2016) was a good diagnostic tool for them, and

was helpful for a self-assessment of their knowledge gaps and learning

needs. They said it aroused their interest and motivation and gave them

some notion of what to expect during the course. This is illustrated in the

following interaction:

“In addition to what [FG2P5] is saying, the pretest was almost very

confusing because it was talking about morphine and pain, a lot of

17

things that I had never heard or seen in my life. So it made me to

know what to expect during the course and it really enhanced my

learning” (FG2P2).

The availability of supplemental learning resources, like the palliative care

toolkit participants’ manual, developed by Lavy and Woodridge (2008) that

was used during the course, was found to be significant in keeping them

engaged throughout the course, and this facilitated their learning.

“… there was a textbook given to us...we could go back home and

relook at what had been taught... and to come back to the next class,

at least half prepared” (FG1P3)

ii. The novelty and relevance of course content

Engaging with new content was particularly important to these students

and raised their enthusiasm for learning during the course.

“What enhanced my learning was the fact that it… was a new field, I

have never heard of it before... I wanted to learn everything that I

could learn” (FG2P2).

“…the pictures I saw, I don’t think I have seen something worse than

that in the hospital...the pictures really raised a lot of preparedness

and it enhanced my understanding a lot” (FG3P5).

Students reported that the emphasis on the message that ‘there is always

something you can do in palliative care’, by the facilitators, was significant

to their learning. This seems to have been the take home message from

the course:

18

“The fact that they brought in the concept that in palliative

care…there is always something that we can do. That was really

significant to me” (FG2P1).

B. Students’ perception of the weaknesses of the course and

suggestions for enhancement

i. Lack of a supervised clinical practice in palliative care nursing

curricula

A major weakness talked about by almost every student was the lack of

supervised clinical practice component of the course. Although they

appreciated the theoretical component, they said they needed to have real

encounters with palliative care patients, practice with them and receive

feedback on their practice from experienced nurses, with palliative care

skills.

“The only thing that I can say did not meet up with my expectation

was that I will have loved to have a working example...to have a

patient in the hospital that the lecturers were following up” (FG1P2).

Some students described instances during the course where they wished

they were provided with more practical and hands-on experiences to

enhance their learning. This was often with regards to pain management,

administering morphine, and communicating with patients and their

relatives.

19

“When I started finding out that morphine was of great use in this

field, actually I have never seen morphine, so I thought maybe they

will bring some of it to class. Also,…I was thinking like maybe we

could have an opportunity to go down (to the hospital) and see how

a palliative setting looks like” (FG3P5).

This desire for a supervised clinical practice in palliative care motivated one

student, to visit one of the course facilitators in the palliative care unit

where he works to experience palliative care in practice:

“… I took off time to go to [name of hospital withheld]…to see what

it was all about, taking care of those who are dying ... I had to witness

how the nurse took care of a cancer patient and for me what was

thought in class and what I saw in the hospital is really the

same”(FG3P7).

ii. Work overload and extensive course duration

Most of the students felt they were overloaded with material over a day’s

session and they found it challenging to accommodate this large volume

over a very short time. The following interaction demonstrates this point:

“What did not work well for me is that…we were taught so many

things in one day” (FG1P5).

“I agree with the point that my friend said. I think that teaching too

many things in one day was a problem”(FG1P1).

Some of them felt that the sessions were too lengthy and they found it

uneasy sitting through the long sessions. Here is what one student said:

20

“... I really got very angry with the time issue, because it was really

long. I have never sat in place like that for just one thing” (FG3P1).

iii. Poor facilitation

Poor examples of facilitation were also recounted as a weakness. Students

complained that some facilitators used ineffective facilitation strategies, like

presenting lengthy explanations, which sometimes made the sessions

boring.

“Some of the facilitators were, I don’t know if that is the way they

talk, but they were at times really boring” (FG2P4).

iv. Poor psychological climate

Students recounted certain classroom experiences that they were not

happy with because it had negative impacts on their emotions and made

them to develop negative feelings about the topic of palliative care. Firstly,

the fact that during the course dying was a major concept talked about

aroused paralyzing fear, as well as death related concerns and anxieties in

some students. Secondly some students were not comfortable when in

citing examples facilitators referred to them or inquired what their own

thoughts were regarding their own dying.

“Another problem I faced during the course was just the terms that

were used. Like the [name of facilitator withheld], was just like

referring it to us, somebody like me I was scared of it. He was using

21

us like an example, so I became so depressed in the class, and I don’t

know, I did not like the course again” (FG2P3).

“… all along the palliative care course, they were only talking about

dying, dying, dying, dying. So everything I was just hearing was

dying, dying, so it was really disturbing” (FG2P5)

Discussion

This evaluation of a palliative care course for preregistration nursing

students in Cameroon indicates a felt need for palliative care education

among the students who took part in this study. Other researchers have

demonstrated a similar desire among nursing students for palliative care

content in their training curriculum, to enhance their skills to care for the

dying (Mutto et al., 2012; Leighton and Dubas, 2009).

A mix of both didactic and experiential learning strategies is considered

integral to effective learning in palliative care (Wee and Hughes, 2007). In

this study, like in others, providing students with supplemental educational

resources like the palliative care manuals and textbooks, was a good

strategy to boost the course and bridge the limited presence of palliative

care contents in core medical-surgical nursing textbooks (Pullis, 2013;

Dobbins, 2011; DiBartolo and Seldomridge 2009).

22

A similar feeling regarding the lack of a supervised clinical practice

component of the course was expressed by participants of an

interdisciplinary palliative care workshop in Botswana who commented that

field or clinical experiences would have strengthened the workshop (Ersek

et al., 2010). In another study conducted in Australia, medical students

who did not have the opportunity to interact with dying patients after taking

part in palliative care education expressed this as a major concern while

those who had the opportunity described it as the best part of their

palliative care learning (Brand et al., 2015). Moreover, graduates of a

postgraduate distance learning course in palliative care for doctors in South

Africa strongly recommended the inclusion of a practical component in their

curriculum, in order to enhance theoretical learning (Ens et al., 2011).

Some commentators have noted that palliative care courses that do not

incorporate high quality practice placement with adequate student support

and optimization of learning opportunities can be misjudged as theoretical

and unrelated to practice. The consequence of which can be a widening of

the theory-practice gap (Gamondi et al., 2013). Adequate clinical

experience in the care of patients and their families who are approaching

the end of life is therefore fundamental to palliative care education and

valuable to authentic learning about palliative care (Centeno et al., 2016;

Gallagher et al., 2014). Nevertheless, the challenge for Cameroon will be

the limited availability of palliative care placement sites and competent

clinical mentors who can be role models of evidence based palliative care

and who can support students in clinical practice. Although simulations can

23

be used to breach this gap to some extent (Eaton et al., 2012; Moreland et

al., 2012; Leighton and Dubas, 2009), they require funds to design and run

them as well as training of nurse educators in the design and use of this

modern technology. Thus a train-the-trainer course to adequately develop

course faculty, including classroom teachers and clinical mentors is needed

to overcome this potential barrier. Brajtman et al. (2009) note that the

need to integrate palliative care content in preregistration nursing

curriculum, necessitates faculty development and support. Train-the-

trainer courses have been shown to improve on this expertise, and a good

example of this is the ELNEC project that trains nurse educators to teach

palliative care, both in the USA and internationally (Malloy et al., 2014;

Malloy et al., 2008). In addition there is a great need for the development

of palliative care policies in the country. With these in place, general

hospital settings, which are said to be of equal benefit to a placement in a

specialist palliative care setting, if students are adequately supported, can

serve as placement sites for students (Gamondi et al., 2013).

Death anxiety is normal and expected when talk about death and dying are

initiated or when a dying patient is experienced (Gallagher et al., 2014;

Leighton and Dubas, 2009). Moreover, participation in a course on palliative

care can bring to mind some emotionally loaded past personal experiences

of dying (Weismann, 2011; Leighton and Dubas, 2009; Brien et al., 2008).

Thus such anxieties need to be appropriately managed during palliative

care courses, to prevent them from becoming overwhelming. Generally, in

24

planning the delivery of palliative care education to preregistration nurses,

it is imperative to consider the need for relevant and manageable contents,

including clinical practice, good facilitation, good psychological climate, as

well as interactive educational strategies to enhance students’ participation

and learning.

Limitations

This study only utilised a volunteer sample from one university which limits

the generalisability of the study findings to the general population of

preregistration student nurses in Cameroon. However, the optional nature

of the course might have facilitated the recruitment of students with an

interest in palliative care. Furthermore, conducting the course evaluation

focus groups two months after students had completed the course might

have compromised students’ recall of their experiences during the course,

and thus their report of this in the focus groups.

Conclusion

Preregistration nursing students are supportive of and willing to participate

in palliative care education. However, they require educational approaches

that are interactive and which include a variety of strategies to enhance

their learning in palliative care. The findings from this study suggest that it

is important to include a supervised clinical practice component in palliative

care programs for preregistration nursing students, to enable them to refine

25

and consolidate skills learnt in theory in a safe and supportive learning

environment. However this will require a train-the-trainer program to

enable palliative care experts to prepare both nurse educators, and clinical

mentors who can educate and support preregistration nursing students’

theoretical and practical learning in palliative care in Cameroon, as well as

other resource-poor settings. The challenge to develop and implement a

train-the-trainer course in Cameroon, given the lack of expertise in the field

of palliative care in this country, will require collaboration with experts in

the field for program development, implementation and mentorship, as has

been the case in other resource-poor settings (Hospice Africa Uganda,

2014; Malloy et al., 2014). Moreover, successful implementation would

depend to a greater degree on the expertise and commitment of the course

facilitators; administrative support for timetabling, and allocation of

resources, as well as support from clinical placement sites and mentors.

This resonates with the views of Sullivan et al., (2004) and Ddungu (2011)

that the success of palliative care education requires the involvement of

Deans and other healthcare education opinion leaders as well as the

learners themselves.

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